Dobutamine stress echocardiography is a useful tool for the assessment of patients with coronary artery disease in different clinical settings. However, its use is significantly limited by poor ultrasound window in a considerable number of patients with this condition. An alternative approach for imaging of the heart has been transesophageal echocardiography. To determine the utility of transesophageal echocardiography combined with dobutamine stress for the evaluation of patients with coronary artery disease, we performed studies in 50 unselected patients who underwent coronary angiography. Forty-three patients were male; age was 59+/-10 years. Images were obtained with a biplane (40 patients) or an omniplane (10 patients) probe. Dobutamine was infused with stepwise increases from 2.5 to 40 microg/kg/min. The left ventricle was divided into 16 segments for regional wall motion analysis. Adequate endocardial visualization to permit analysis of regional wall motion was achieved in a greater number of myocardial segments with transesophageal compared to transthoracic echocardiography. Forty of the 50 patients had significant stenosis (more than 70% of at least 1 major coronary artery). Dobutamine induced new wall motion abnormality in 35 patients with coronary artery disease and in no patient with normal coronary arteries. Regional wall motion abnormalities in the distribution of at least 2 major coronary arteries were observed in 17 of the 19 patients with multi-vessel coronary artery disease and in only 1 of the 21 patients with single-vessel coronary artery disease. Thus, the sensitivity of the test was 88%, with a specifity and a positive predictive value of 100%. In only 2 patients the test was stopped because of intolerance to the probe. No complications occurred in any of our studies. Thus, this study indicates that transesophageal dobutamine stress echocardiography is a useful tool for the assessment of coronary artery disease and therefore should be considered in patients undergoing stress echocardiography who have suboptimal transthoracic ultrasound window.